Statin Intensity Ladder
Map any statin dose to its ACC/AHA intensity tier and list equivalent options at the same intensity.
- Choosing initial statin therapy after a new ASCVD diagnosis or risk-based primary prevention decision
- Switching a patient between statins (formulary, tolerability, drug interaction)
- Reconciling a "moderate intensity" home dose against what the discharge summary actually intends
- Sanity-checking that simvastatin 40 mg is not high-intensity therapy
- Intensity is a tier, not a mg. Atorvastatin 40 ≈ rosuvastatin 20 ≈ "high intensity"; cross-converting at the mg level is the wrong question.
- Only atorvastatin and rosuvastatin can deliver high intensity. Simvastatin tops out at moderate (and 80 mg should not be used in new patients).
- Don't down-titrate without a reason. Patients on 80 mg atorvastatin "can't tolerate it" suspiciously often; a careful symptom history before dropping a tier preserves benefit.
- Pitavastatin and pravastatin are the agents of choice when CYP3A4 interactions are an issue (HIV regimens, certain antifungals, clarithromycin).
- Pregnancy. All statins are contraindicated in pregnancy; this is a setting where stopping rather than switching is correct.
The most common statin error isn't dose math — it's substitution at "equivalent mg" instead of "equivalent intensity." Showing the intensity tier explicitly, with all the in-tier options listed, makes the right substitution obvious.
Estimated LDL-C reduction
49%
Intensity
moderate
High-intensity options
≥50% LDL-C reduction
- Atorvastatin 40 mg/day
- Atorvastatin 80 mg/day
- Rosuvastatin 20 mg/day
- Rosuvastatin 40 mg/day
Moderate-intensity options
30–49% LDL-C reduction
- Atorvastatin 10 mg/day
- Atorvastatin 20 mg/day
- Rosuvastatin 5 mg/day
- Rosuvastatin 10 mg/day
- Simvastatin 20 mg/day
- Simvastatin 40 mg/day
- Pravastatin 40 mg/day
- Pravastatin 80 mg/day
- Lovastatin 40 mg/day
- Fluvastatin 80 mg/day
- Pitavastatin 1 mg/day
- Pitavastatin 2 mg/day
- Pitavastatin 4 mg/day
Frequently asked
What is the equivalent of atorvastatin 40 mg?
Atorvastatin 40 mg is high-intensity therapy. The equivalent high-intensity options are atorvastatin 80 mg or rosuvastatin 20–40 mg. No other statin reliably delivers high-intensity reduction; simvastatin, pravastatin, and lovastatin top out at moderate intensity.
Is rosuvastatin 10 mg high intensity?
No. Rosuvastatin 10 mg is moderate intensity (~43% LDL-C reduction). Rosuvastatin 20–40 mg achieves high intensity (≥50% reduction). The most common substitution error is treating "rosuvastatin" as a brand without confirming the dose tier.
Why is simvastatin 80 mg no longer recommended?
The FDA issued a safety communication in 2011 restricting simvastatin 80 mg in new patients after a meta-analysis showed substantially increased rhabdomyolysis risk, particularly in combination with amlodipine, amiodarone, ranolazine, or other CYP3A4 inhibitors. Existing patients tolerating 80 mg for >12 months are sometimes continued, but new starts should not exceed 40 mg.
Can I convert simvastatin 40 mg to atorvastatin?
Simvastatin 40 mg is moderate intensity (~37% LDL-C reduction). The equivalent atorvastatin dose is 10–20 mg/day for the same intensity tier. If the goal is to step up to high intensity (e.g., new ASCVD diagnosis), switch to atorvastatin 40–80 mg or rosuvastatin 20–40 mg.
Is rosuvastatin or atorvastatin better?
For raw LDL-C lowering, rosuvastatin is mg-for-mg slightly more potent. For cardiovascular outcomes, both are first-line and the head-to-head data (e.g., SATURN) showed similar event rates. The choice usually comes down to drug interactions (rosuvastatin has fewer CYP3A4 interactions), cost / formulary, and renal function (rosuvastatin requires dose-reduction at CrCl <30).